Ethical Dilemmas in Elderly Cancer Patients: A Perspective From the Ethics of Care

The heart of palliative care is relational: a scoping review of the ethics of care in palliative medicine

BACKGROUND

Palliative care, perhaps more than any subspecialty in healthcare, is deeply relational and engages patients and families at times of great vulnerability. Ethics of care, or relational ethics, developed through contributions from feminist ethics, offers conceptual tools and ways of thinking that seem especially suited to palliative care practice.

AIM

To identify and describe studies and theoretical analyses applying the ethics of care to palliative care (both adult and paediatric), specifically, its use to guide and improve practice and education for palliative care practitioners.

DESIGN

We conducted a scoping review of six databases covering clinical, social science and normative ethics scholarship and conducted a thematic analysis of the findings and ethical discussions or arguments.

DATA SOURCES

Databases searched included PubMed, CINAHL, PsychINFO, EMBASE, Web of Science and Philosopher's Index from 1982 to November 2024.

RESULTS

30 publications meeting our inclusion criteria were identified. Major themes reflected the relational obligations, attributes and character traits ideally developed in palliative care providers in their work and relationships with patients and families, including responsiveness, connectedness and hope, as well as in caring for ourselves and each other on palliative care teams. An emerging literature recognises the special guidance for palliative care for children.

CONCLUSIONS

Clinical and ethical scholarship in palliative care reveals a valuable but still underexplored connection between the ethical commitments within the ethics of care tradition and palliative care training and practice. Ethics of care addresses important gaps in training, particularly having to do with practitioners' relationships and ways of being with patients, families, colleagues and themselves.

Psychological health in Palliative Care: Thematic analysis of a psychiatrist's and an art therapist's clinical reflexive journals

BACKGROUND

Patients receiving palliative care often face psychological distress, which can be challenging for clinicians to manage. Therefore, reflexive and visual journaling can be used as powerful techniques for clinician selfreflection and personal development. These journals are a form of practice wisdom, providing insights into psychological health in palliative care.

AIM

This study aims to describe how patients receiving palliative care experience psychological health, explore the meaning of a palliative care clinician's work and contribute to the understanding of psychological health in palliative care through the reflexive and visual journals of clinicians.

DESIGN

Using Gibb's reflective cycle as a framework for journaling, this study employs reflexive and visual journaling through the lenses of a psychiatrist and an art therapist. Journal data were analysed using a thematic analysis approach.

SETTING/PARTICIPANTS

The two first authors journaled 107 clinical encounters and created 36 pieces of response art detailing encounters with patients and their families, and clinical conversations in two palliative care centres.

RESULTS

Patient attributes and the clinical environment were observed to influence psychological health in palliative care. The patient's ability to navigate dying, maintain personhood, exert resilience and experience satisfying relationships contribute to psychological health. A clinical environment comprising clinicians with holistic competencies, systems promoting interdisciplinary collaborations and a values-based culture that promotes patient centricity strengthens the delivery of psychological care.

CONCLUSIONS

Good psychological health in palliative care extends beyond psychopathology and is influenced by the cardinal elements of being human, value systems and systemic elements in the therapeutic environment.

Care ethics framework for midwifery practice: A scoping review

Background: As a normative theory, care ethics has become widely theorized and accepted. However, there remains a lack of clarity in relation to its use in practice, and a care ethics framework for practice. Maternity care is fraught with ethical issues and care ethics may provide an avenue to enhance ethical sensitivity.Aim: The purpose of this scoping review is to determine how care ethics is used amongst health professions, and to collate the information in data charts to create a care ethics framework and definition for midwifery practice.Method: The scoping review was conducted according to the Preferred Reporting Items for Scoping reviews (PRISMA-ScR) and Joanna Briggs Institute (JBI) recommendations. The search was applied to the databases CINAHL, MEDLINE, PschInfo and Pubmed which were searched in September 2019 and again in July 2021. The inclusion criteria were guided by the mnemonic for search terms: Participants, Concept, and Context (PCC) and included variations of health care professionals, care ethics and utilization. The search was limited to qualitative studies published in English between 2010 and 2021. A data extraction tool was used to extract and synthesize data into categories. The articles were screened for eligibility by title, abstract and full text review, by two independent reviewers.Ethical Considerations: The scoping review was guided by ethical conduct respecting authorship and referencing sources.Results: Twelve of the initially identified 129 studies were included in the scoping review. Data synthesis yielded four categories of care ethics use by health professionals: relationship, context, attention to power and caring practices. In combination, the evidence forms a framework for care ethics use in midwifery practice.Conclusion: Care ethics use by health professionals enhances ethical sensitivity. A framework and definition for care ethics for midwifery practice is proposed. This review will be of interest to midwives and other health practitioners seeking to enhance ethical sensitivity.

Does midwifery-led care demonstrate care ethics: A template analysis

BACKGROUND

Ethical care in maternity is fundamental to providing care that both prevents harm and does good, and yet, there is growing acknowledgement that disrespect and abuse routinely occur in this context, which indicates that current ethical frameworks are not adequate. Care ethics offers an alternative to the traditional biomedical ethical principles.

RESEARCH AIM

The aim of the study was to determine whether a correlation exists between midwifery-led care and care ethics as an important first step in an action research project.

RESEARCH DESIGN

Template analysis was chosen for this part of the action research. Template analysis is a design that tests theory against empirical data, which requires pre-set codes.

PARTICIPANTS AND CONTEXT

A priori codes that represent midwifery-led care were generated by a stakeholder consultative group of nine childbearing women using nominal group technique, collected in Perth, Western Australia. The a priori codes were applied to a predesigned template with four domains of care ethics.

ETHICAL CONSIDERATIONS

Ethics approval was granted by the Edith Cowan University research ethics committee REMS no. 2019-00296-Buchanan.

FINDINGS

The participants generated eight a priori codes representing ethical midwifery care, such as: 1.1 Relationship with Midwife; 1.2 Woman-centred care; 2.1 Trust women's bodies and abilities; 2.2. Protect normal physiological birth; 3.1. Information provision; 3.2. Respect autonomy; 4.1. Birth culture of fear (midwifery-led care counter-cultural) and 4.2. Recognition of rite of passage. The a priori codes were mapped to the care ethics template. The template analysis found that midwifery-led care does indeed demonstrate care ethics.

DISCUSSION

Care ethics takes into consideration what principle-based bioethics have previously overlooked: relationship, context and power.

CONCLUSION

Midwifery-led care has been determined in this study to demonstrate care ethics, which suggest that further research is defensible with the view that it could be incorporated into the ethical codes and conduct for the midwifery profession.

Ethical Conflicts Experienced by Nurses in Geriatric Hospitals in South Korea: "If You Can't Stand the Heat, Get Out of the Kitchen"

Ethical conflicts among nurses can undermine nurses’ psychological comfort and compromise the quality of patient care. In the last decade, several empirical studies on the phenomena related to ethical conflicts, such as ethical dilemmas, issues, problems, difficulties, or challenges, have been reported; however, they have not always deeply explored the meaning of ethical conflicts experienced by nurses in geriatric care. This study aims to understand the lived experiences of ethical conflict of nurses in geriatric hospitals in South Korea. A phenomenological study was conducted. In-depth, face-to-face interviews were performed with nine registered nurses who cared for elderly patients in geriatric hospitals in South Korea between August 2015 and January 2016. Three main themes emerged from the analysis: (1) confusing values for good nursing, (2) distress resulting from not taking required action despite knowing about a problem, and (3) avoiding ethical conflicts as a last resort. It was found that for geriatric nurses to cope with ethical conflicts successfully, clear ethical guidance, continuing ethics education to improve ethical knowledge and moral behaviors, and a supportive system or program to resolve ethical conflicts involving nurses should be established.

"I go into crisis when …": ethics of care and moral dilemmas in palliative care

Background

Recognising and knowing how to manage ethical issues and moral dilemmas can be considered an ethical skill. In this study, ethics of care is used as a theoretical framework and as a regulatory criterion in the relationship among healthcare professionals, patients with palliative care needs and family members.

This study is a part of a larger project aimed at developing and implementing a training programme on “ethical communication” addressed to professionals caring for patients with palliative care needs. The aim of this study was comprehending whether and how the ethics of care informs the way healthcare professionals make sense of and handle ethical issues in palliative care.

Methods

Qualitative study employing a theoretically driven thematic analysis performed on semi-structured interviews.

The research was conducted in a clinical cancer centre in northern Italy. Eligible participants were physicians and nurses from eleven hospital wards who assisted patients with chronic advanced disease daily and had previously attended a 4-h training on palliative care held by the hospital Palliative Care Unit.

Results

The researchers identified five themes: morality is providing global care; morality is knowing how to have a relationship with patients; morality is recognizing moral principles; moral dimension and communication; and moral dilemmas are individual conflicts.

Conclusions

Ethics of care seems to emerge as a theoretical framework that includes the belief systems of healthcare professionals, especially those assisting patients with palliative care needs; moreover, it allows the values of both the patients and professionals to come to light through the relationship of care. Ethics of care is also appropriate as a framework for ethical training.

What healthcare teams find ethically difficult

Background:

Ethically difficult situations are frequently encountered by healthcare professionals. Moral case deliberation is one form of clinical ethics support, which has the goal to support staff to manage ethical difficulties. However, little is known which difficult situations healthcare teams need to discuss.

Aim:

To explore which kinds of ethically difficult situations interprofessional healthcare teams raise during moral case deliberation.

Research design:

A series of 70 moral case deliberation sessions were audio-recorded in 10 Swedish workplaces. A descriptive, qualitative approach was applied, using thematic content analysis.

Ethical considerations:

An advisory statement specifying no objections to the study was provided from an Ethical Review Board, and consent to be recorded was assumed by virtue of participation in the moral case deliberation.

Findings:

Three themes emerged: powerlessness over managing difficult interactions with patients and next-of-kin, unease over unsafe and unequal care, and uncertainty over who should have power over care decisions. The powerlessness comprised feelings of insufficiency, difficulties to respond or manage patient’s/next-of-kin’s emotional needs or emotional outbursts and discouragement over motivating patients not taking responsibility for themselves. They could be uncertain over the patient’s autonomy, who should have power over life and death, disclosing the truth or how much power next-of-kin should have.

Discussion:

The findings suggest that the nature of the ethically difficult situations brought to moral case deliberations contained more relational-oriented ethics than principle-based ethics, were permeated by emotions and the uncertainties were pervaded by power aspects between stakeholders.

Conclusion:

MCD can be useful in understanding the connection between ethical issues and emotions from a team perspective.

Novel ethical dilemmas arising in geriatric clinical practice

The purpose of this study is to determine empirically the state of the art of the medical care, when healthcare personal is confronted with ethical dilemmas related with the care they give to the geriatric population. An observational, longitudinal, prospective and qualitative study was conducted by analyzing the correlation between healthcare personnel-patient relationship, and ethical judgments regarding dilemmas that arise in daily clinical practice with geriatric patients. Mexican healthcare personnel with current active practices were asked to write up an ethical dilemma that arose frequently or that had impacted their medical practice. From the narrative input, we were able to draw up a database with 421 dilemmas, and those corresponding to patients 60 years and older were selected (n = 54, 12.8 %). The axiological analysis of the narrative dilemmas of geriatric patients was made using dialectical empiricism. The axiological analysis values found most frequently were classified into three groups: the impact of healthcare, the roles of the physician, and refusal of therapy; the healthcare role of educator, caring for the patients' life and the risk of imminent death where the values found more often. The persistence and universality of certain dilemmas in geriatrics calls for awareness and requires a good training in the ethical discernment of these dilemmas. This would help to improve substantially the care and the life quality of this population.

Challenging situations when administering palliative chemotherapy - a nursing perspective

Palliative chemotherapy treatments (PCT) are becoming more common for patients with incurable cancer; a basic challenge is to optimize tumour response while minimizing side-effects and harm. As registered nurses most often administer PCT, they are most likely to be confronted with difficult situations during PCT administration. This study explores challenging situations experienced by nurses when administering PCT to patients with incurable cancer.

METHODS

Registered nurses experienced in administering PCT were asked in interviews to recall PCT situations they found challenging. Inspired by the narrative tradition, stories were elicited and analysed using a structural and thematic narrative analysis.

RESULTS

A total of twenty-eight stories were narrated by seventeen nurses. Twenty of these were dilemmas that could be sorted into three storylines containing one to three dilemmatic situations each. The six dilemmatic situations broadly related to three interwoven areas: the uncertainty of the outcome when giving potent drugs to vulnerable patients; the difficulty of resisting giving PCT to patients who want it; and insufficient communication between nurses and physician.

CONCLUSION

Nurses who administer PCT are engaged in a complex task that can give rise to a number of dilemmatic situations. The findings may be interpreted as meaning that at least some situations might be preventable if the knowledge and insight of all team members - nurses, physicians, patients, and relatives - are jointly communicated and taken into account when deciding whether or not to give PCT. Forming palliative care teams early in the PCT trajectory, could be beneficial for staff and patients.